Firm Foundations Ministries

Release of Information Form

Initial only the appropriate boxes:

 Initials Text fieldI authorize Firm Foundation Ministries to provide and receive information from:

● State and Government Agencies on my behalf for the purpose of assisting me with
obtaining vital records and identification documents.
● Emergency Contact Person, Medical Providers i.e. (ER, Rehab, Detox) etc.
● Parole Officers, Volunteers, Mentors
● FFM Staff: We enjoy sharing your success stories, also we may need to make contact with
other transitional living homes, possible future landlords, etc

o I consent to the use of any testimonies or stories I give to FFM. (Initial)Initials Text field
o I consent to the use of photos that may be taken at an event or a portrait of
yourself to compliment your story. (Initial)Initials Text field

OR

Initials Text fieldI have chosen NOT to complete this form, and I decline to give permission to FFM to
communicate with anyone on my behalf. In doing so, I understand that FFM may not be able
to support my request for accommodations.

Participant Signature
Signature

Date of Authorization Date
Name: Client first name Client last name
DOB:Client birthdate SSN:SSN
Current Address: Client Address Client City  Client State Client Zip
Phone #: Client phone
Emergency Contact & Phone #:Text field Text field
Relationship: Text field Phone #: Text field